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March 10th, 2020
Muhammad Jawaid, MD
Meritus Family Medicine Residency Program
11116 Medical Campus Road,
Hagerstown, MD 21742
To the Editor,
I would like to express my appreciation to the authors of the article, Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial, for shedding light on the lack of adherence and emphasis physicians tend to give to the technique of using an inhaler. Having read the article, I would like your clarification on a few points I noted, which are as follows:
While the ‘Loss to follow-up was greater for the health-coaching arm than for the usual-care arm’, the author does not specify why the number of people who dropped out of the study was higher in the intervention group than the control group. A greater number of people in the intervention group were smokers (99% vs 93.4%) and used LAMA (59% to 40%), both of which were statistically significant for differences between the groups. Despite conducting two sensitivity analyses for missing data, it is unclear if these differences between the groups influenced the outcome of the study in any way. It is also not evident whether the people who were lost to follow up actually benefitted from health-coaching and decided that they no longer needed to follow up or their health deteriorated to the point that they were no longer able to keep up with the follow-up requirements of the trial.
This study was conducted in a Black/African American or Hispanic community, where a large percentage of people had an income less than $10,000 a year. It is reasonable to assume that the loss of patients from the intervention group may be due to participants not being able to afford the cost of medications and adhered to the daily treatment plan. This would explain why patients dropped out of the study by 9 months.
In Figure 1, it is apparent that the significance of number of people who ‘used controller inhaler at baseline’ versus ‘used rescue or controller inhaler at baseline’ is that one can measure ‘adherence’ to inhaler use at 9 months with the former. While it is evident how you measured ‘adherence’, it is equivocal that you use the latter to measure the ‘technique’ at baseline as well as at 9 months. If so, the separation between measurements for both adherence and technique require clarification.
Lastly, the author did not specify in the discussion what could have been done differently to reach statistical significance for the ‘Perfect adherence’ measure (p-value 0.13) in table 2. It is unclear why it was not attainable after 9 months of coaching and requires an explanation in the discussion section.
While intuitively coaching or close loop teaching should help as the outcome of the study shows, the magnitude of impact as indicated by the low p-value may differ and hence needs further review.
Sincerely,
Muhammad Jawaid, MD
Meritus Family Medicine Residency Program
11116 Medical Campus Road,
Hagerstown, MD 21742
Phone # 301.302.5570